Integrating Behavioral Health and Physical Medicine: Its Time Has Come

The basis for a program that integrates behavioral health and physical medicine (IBHPM) is built on several studies one of which originated from the Government Accountability Office (GAO) in May of 2015. This Congressional document cites, “Among Medicaid-only enrollees, a small percentage consistently accounted for a large percentage of expenditures”. Beneficiaries that fell into this group consisted of the disabled, complex health issue children, duals, and behavioral health. The GAO showed that over half of the Medicaid-only enrollees in the top five percent of expenditures had a mental health condition, and one-fifth had a substance use disorder. These conditions often co-occur; 71 percent of those high-expenditure enrollees with a substance use disorder also lived with one or more co-occurring mental health condition.

It is a well-studied and documented fact that mental health issues increase utilization of both behavioral health and physical medicine. According to CMS under its Medicaid section cites:

“Individuals with mental health needs often have comorbid physical health conditions that require medical attention; more than half of the Medicaid-enrollees in the top five percent of expenditures who had asthma or diabetes also had a behavioral health condition. Furthermore, individuals with co-morbid physical and behavioral health conditions often have worse health outcomes. Although individuals with mental health conditions have some of the greatest health care needs (including complex poly-pharmacy regimens), the health care system is often too fragmented to effectively and efficiently serve them. Behavioral health needs often go undiagnosed or untreated in the primary care setting, and primary care physicians also have a more difficult time referring their patients to mental health services compared to other specialty services.”

Health plans; health centers and hospitals around the country are moving into the integration mode. The move away from the traditional “carve out” model has been clearly documented over the years. Some of the causes that have plagued the industry are those relating to the problems with access to basic behavioral health (BH) services for primary care providers (PCP) and community health centers (CHC) that have populations with high levels of BH risk. Also, a burden of behavioral healthcare complicates the healthcare delivery process and drives up costs. There have been significant reimbursement barriers for primary care systems when they diagnosis and treat BH conditions and do not apply the DSM protocols.

There was no clear process for BH providers to entertain physical medicine diagnoses or treatment them. Referral back to primary care without an establish protocol and follow-up made any attempts to co-treat these patients was rendered futile. These are but several of the issues that have prevented the collaboration between the two specialty areas. The main thrust has always been in associated with either the severally mentally ill (SMI) patient or the co-morbid medical/surgical (CoMS) patient.

Why was this not thought of before? The key indicators were standing in plain sight. Approximately 50 percent of BH services are delivered by PCPs. Approximately 70 percent of community health patients have behavioral health or cardiac disease. While 92 percent of all elderly patients receive behavioral health care from their PCPs. The top 10 percent of healthcare utilizers consume 33 percent of the outpatient services and 50 percent of all inpatient services. Approximately 50 percent of the high utilizers have behavioral health or cardiac diseases. Lastly, patients who suffer from mental distress use two-time the as much healthcare as compared to those patients that are not in mental distress.

The process of care factors that go into this equation are represented by other factors, such as approximately 25 percent of medical decision-making is based on disease severity. Approximately 70 percent of all primary care visits have psychosocial drivers; while a whopping 90 percent of most behavioral health visits in the primary care setting have not organic basis.

Another eye opener is associated with substance abuse. PCPs tend not to address substance abuse unless is flagrant. Alcohol abuse and other abuses are dealt with in a non-threatening manner or otherwise swept under the rug unless a family member complains about the abuse to the provider. Thereby, a number of alcohol and drug abusers go without treatment until they reach a “point of no-return”.

Another alarming fact is that 67 percent of all psychotropic drugs and 80 percent of all antidepressants are prescribed by PCPs. These numbers are very disturbing and have complicated matters in a very significant and disruptive manner. The vast majority of PCPs that prescribe these medications do not even document the corresponding behavioral health diagnosis for billing and insurance purposes. Albeit this is not only unethical; it is fraudulent. The common citation for these absentee diagnoses is said to be for “protection of the patient from the stigma of mental illness”.

The PCPs view these behavioral health issues as being “intermittent” and do not want to condemn a patient to a diagnosis that can haunt them for a lifetime. Most PCPs look to establish behavioral health diagnoses for only those with severe conditions. The problem is that there is no such diagnosis as “intermittent psychosis” or “occasional depression”.

The reverse is not the case in the world of BH. BH professionals tend to shy away from the diagnosis and treatment of even the simplest of medical and/or surgical diagnoses. Then also tend to overlook them or make fast referrals to specialists with no follow-through with either the patient or specialist. This now places patients in the classic “gaps in care” area of the healthcare delivery system.

The benefits of BH and PM integration are many. To start with, there is improved recognition of both BH and medical/surgical disorders by both the patient and the providers. When PCPs are shown data that clearly indicates that they are overprescribing BH drugs and then given insight and education the number of drugs prescribed goes precipitously down and referrals to therapist and counselors go up. The same goes for BH professionals, the number of referrals and follow through to the PCP and appointed the specialist to go way up. In both cases the increase in confidence in recognizing each other cases and conditions increases.

We know it works because studies have indicated an improvement in depression remission rates range from 42 to 71 percent once patients stop medication and go to therapy. Improvement is self-management skills for a patient with chronic diseases also goes up. In both cases, there is a statistically significant improvement in clinical outcomes, as well as improved patient AND provider satisfaction. There is also a high level of patient adherence and retention in treatment as compared to the historical 50-60 percent non-adherence to psychotropic and antidepressant medication after four weeks of treatment.

The cost effectiveness of this collaborative effort is quite significant according to a number of studies that have taken place over the years. The cost of care integrating these two services adds between $265 and $350 per case, but return double plus that amount in the cost savings associated with high-cost drugs being eliminated and patients not seeking higher cost options for treatment of either their BH or medical/surgical problems. Therefore, the value is in better diagnostic accuracy, treatment by the right provider, at the right time, in the right treatment setting, which all adds up to cost savings.

As cited at the top of this piece, Medicaid programs have seen the highest cost when these two areas remain in their separate silos. There have been significant savings in various pilot programs around the country using the Medicaid populations. Overall, the top savings was at 40 percent. Therefore, it can be done.

This is why the Centers for Medicare and Medicaid Services (CMS) and individual states have studied the cost overruns associated in the various state populations. CMS concluded that they needed to put into place an integration pilot program. That program commenced in January 2017. CMS is focused on four priorities:

1. Substance abuse disorders
2. Complex need and high cost
3. Community integration with long-term services and supports
4. Behavioral and physical health integration

And it has four goals:

1. Improve the behavioral and physical health outcomes and experience of care of individuals with a mental health condition;
2. Create opportunities for programs to link payments with improved quality and outcomes for beneficiaries with these co-morbid conditions;
3. Identify and spread innovations to the field that improve and expand physical and mental health integration initiatives in various settings and for various populations.
4. Expand and/or enhance existing state physical and mental health integration efforts to:

Customize for specific populations; and/or,

Spread integration efforts to new areas of the state; and/or,

Spread integration efforts to new types of health professionals;

Whether you are a health plan, QIO, ACO, PCMH, CHC, or anything in between, you have to put the integration of BH and PM into action. However you choose to do it, you will find that not only are there dollars that you will save, but that you will gain the added benefit of raising health awareness on an individual and given population basis. There are the added effects of early identification and treatment and the prevention of unwanted side effects and co-morbid issues are significantly reduced. Both the patient and the providers see the much-wanted functional outcomes and improvement that they have been looking to achieve.

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#integrated healthcare #integrated behavioral health and primary care #integrated behavioral health and physical medicine #healthcare reform #Medicaid #Medicare #behavioral health and primary care #behavioral health #primary care